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Missed Opportunities in the Outpatient Pediatric Setting to Support Breastfeeding: Results From a Mixed-Methods Study
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Missed Opportunities in the Outpatient Pediatric Setting to Support Breastfeeding: Results From a MixedMethods Study D1X XMary M. Ramos, D2X XMD, MPH, D3X XRachel A. Sebastian, D4X XMA, D5X XEmilie Sebesta, D6X XJD, MD, D7X XAdrienne E. McConnell, D8X XMS, & D9X XCourtney R. McKinney, D10X XBA ABSTRACT Introduction: Outpatient pediatric providers play a crucial role in the promotion of breastfeeding. We conducted a mixed methods Mary M. Ramos, Assistant Professor, Department of Pediatrics, University of New Mexico School of Medicine, Albuquerque, NM. Rachel A. Sebastian, Medical Sociologist, Child Policy Research Consulting, LLC, Fort Wright, KY. Emilie Sebesta, Professor, Department of Pediatrics, University of New Mexico School of Medicine, Albuquerque, NM. Adrienne E. McConnell, Health Education Consultant, Department of Pediatrics, University of New Mexico School of Medicine, Albuquerque, NM. Courtney R. McKinney, Program Manager, Department of Pediatrics, University of New Mexico School of Medicine, Albuquerque, NM.
study to measure provider knowledge, attitudes, and current practices around breastfeeding counseling. Method: In New Mexico in 2016 and 2017, we conducted a knowledge, attitudes, and practice survey of outpatient pediatric providers (i.e., nurse practitioners, physicians, and physician assistants) and conducted focus groups with outpatient pediatric providers. Results: Seventy-seven providers responded to the survey, and 17 participated in three focus groups. Fewer than half of providers surveyed reported asking how long mothers plan to breastfeed at initial well-baby examinations. One quarter of participants (28.2%) erroneously reported that hepatitis C was an absolute contraindication to breastfeeding. Just half of respondents had received continuing education within the past 3 years about managing common breastfeeding problems. Discussion: We identified missed opportunities for outpatient pediatric providers to support breastfeeding and a need for continuing provider education. J Pediatr Health Care. (2018) XX, 1 8
Conflicts of interest: None to report. This work was supported by the W.K. Kellogg Foundation (grant number P3034276) and the New Mexico Human Services Department (grant number 14-630-8000-0008 A2). The funding agencies played no role in the study design; collection, analysis and interpretation of data; in the writing of this article; or in the decision to submit this article for publication.
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Correspondence: Mary M. Ramos, MD, MPH, MSC 10 5590, 1 University of New Mexico, Albuquerque, NM 87131-0001; e-mail: [email protected]. J Pediatr Health Care. (2018) &&, && &&
INTRODUCTION There is overwhelming evidence of the benefits of breastfeeding for both infants and women. Because of this evidence, the American Academy of Pediatrics (AAP), American Academy of Family Physicians (AAFP), American College of Obstetricians and Gynecologists (ACOG), National Association of Pediatric Nurse Practitioners, and the World Health Organization recommend exclusive breastfeeding for the first 6
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Breastfeeding, breastfeeding support, outpatient, provider confidence, provider knowledge
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ARTICLE IN PRESS months of a child’s life and continued breastfeeding after the introduction of complementary foods for at least 1 to 2 years (AAFP, n.d.; AAP, 2012; ACOG Committee on Health Care for Underserved Women, 2007; ACOG Committee on Obstetric Practice Breastfeeding Expert Work Group, 2016; National Association of Pediatric Nurse Practitioners, 2013; World Health Organization, n.d.). However, approximately half of the women in the United States who initiate breastfeeding will discontinue breastfeeding by 6 months (Centers for Disease Control and Prevention, 2017). In the United States alone, an estimated 2,619 annual maternal deaths (mostly due to myocardial infarction, breast cancer, and diabetes) and 721 annual pediatric deaths (mostly due to sudden infant death syndrome and necrotizing enterocolitis) are attributed to this suboptimal breastfeeding (Bartick et al., 2017). The estimated annual medical costs of suboptimal breastfeeding in the United States total $3.0 billion (Bartick et al., 2017). Outpatient pediatric practices play a crucial role in the promotion and support of breastfeeding (Kornides & Kitsantas, 2013; Meek et al., 2017). Provider interventions, for example, counseling and information, have a significant effect on the initiation and duration of exclusive breastfeeding in the first 6 months of life and overall duration (Kornides & Kitsantas, 2013; Odom, Li, Scanlon, Perrine, & Grummer-Strawn, 2014; Patnode, Henninger, Senger, Perdue, & Whitlock, 2016). Women are more likely to initiate breastfeeding when their providers are supportive of exclusive breastfeeding (Kornides & Kitsantas, 2013; Odom et al., 2014). Furthermore, women who have knowledge of breastfeeding recommendations are less likely to discontinue breastfeeding than women who do not have knowledge of breastfeeding recommendations (Wallenborn, Ihongbe, Rozario, & Masho, 2017). Breastfeeding support interventions, including educational counseling and referrals, are associated with increased rates of any and exclusive breastfeeding (Patnode et al., 2016; Skouteris et al., 2014). Previous findings also support the use of lactation consultants and peer counselors (Bibbins-Domingo et al., 2016; Bonuck et al., 2014). Because of the direct link between breastfeeding and maternal and infant health outcomes, the AAP recommends that all pediatric care providers work to improve breastfeeding rates in their practices and has published guidance on establishing breastfeeding-friendly pediatric office practices (Meek et al., 2017). The Tri-core Breastfeeding Model (Busch et al., 2014) provides a framework for pediatric nurse practitioners to integrate evidencebased knowledge, skills, and attitudes supportive of breastfeeding into their clinical practices. The model emphasizes sustainability for the mother baby dyad through maternal self-efficacy, lactation support, and lactation education for mothers and health care professionals (Busch, Logan, & Wilkinson, 2014). As a foundational step of a planned public health intervention aimed at increasing breastfeeding exclusivity and duration, we surveyed outpatient pediatric providers (i.e., nurse practitioners, physicians, and physician assistants) to measure their 2
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knowledge, attitudes, and current practices around breastfeeding counseling and support. We also conducted focus groups with outpatient pediatric providers to confirm We sought to and triangulate survey identify gaps findings. We sought to identify gaps between between best best practices and actual practices and actual provider knowledge and provider knowledge counseling.
and counseling. METHODS Survey Instrument Subject matter experts in pediatrics, nursing, public health, and quality improvement created the 51-item survey instrument to measure the breastfeeding knowledge, confidence, and counseling practices of outpatient pediatric providers (i.e., nurse practitioners, physicians, and physician assistants). The survey was then cognitively tested by four pediatric providers to ensure content validity before administration. Specific survey domains included demographics, professional characteristics, knowledge of current professional guidance around breastfeeding, breastfeeding counseling practice, confidence in their counseling, and continuing education. Administration The survey was conducted anonymously. The survey instrument was administered in paper copy to providers who attended the New Mexico Pediatrics Society annual meeting in Albuquerque, New Mexico in August 2016, and then the identical survey was administered electronically using Research Electronic Data Capture (i.e., REDCap; Harris et al., 2009). Members of the New Mexico Pediatric Society, the University of New Mexico General Pediatrics and Family Medicine faculty, and outpatient provider groups across the state, including eight federally qualified health centers, were contacted through e-mail and asked to complete the survey. The e-mail notice included an anonymous Web link to the REDCap survey. Two weeks after the initial e-mail notice, a reminder notice with the Web link to the survey was e-mailed. Completed surveys were received from August 2016 through December 2016. Data analysis We included all respondents to the survey who self-identified as being an outpatient pediatric provider (i.e., nurse practitioners, physicians, and physician assistants). The study design was cross-sectional. We calculated proportions and frequencies. Focus Groups We conducted focus groups with pediatric providers in the two largest metropolitan areas of the state. The first two were held in central New Mexico on April 21, 2017, and the
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ARTICLE IN PRESS TABLE 1. Percentage of providers who always ask about breastfeeding at well-baby visits— New Mexico Pediatric Provider Survey, 2016 Providers who always ask at first or second visit, % How long mothers plan to exclusively breastfeed How long mothers plan to breastfeed in total
40.8 31.0 Providers who always ask at specific well-baby visits, %
If baby is breastfeeding, formula-feeding, or both If breastfeeding, any problems or concerns If breastfeeding, plans to continue after returning to work or school
1st Newborn Visit
10- to 14-Day Visit
2-Month Visit
4-Month Visit
98.6 94.4 56.9
97.2 95.7 59.2
94.4 53.6 65.7
94.4 34.3 Not asked
Note. N = 77 family and pediatric nurse practitioners, family medicine and pediatric physicians, and physician assistants.
third was held in southern New Mexico on June 16, 2017. Providers in the focus groups were asked semistructured questions about their attitudes toward breastfeeding, knowledge and agreement with breastfeeding recommendations, sense of role responsibility related to breastfeeding counseling and support, current practices, and readiness to improve breastfeeding supports in their practices. Focus groups were conducted by four study members: two pediatricians and two quality improvement experts. Each focus group included at least one interviewer and one note taker. Notes were taken by hand, transcribed, and first reviewed by one study team member with expertise in qualitative data to examine common themes versus concerns of individual participants. The final themes that emerged were constructed through a consensus of study team members. Ethical Review The study protocol was approved by the authors’ Human Research Protections Office (HRC HRPO # 6-200). RESULTS Survey Findings Participants A total of 77 outpatient pediatric providers participated in the survey. Most (75%) were 40 years old or older. Most participants (59.5%) were non-Hispanic White; 27.0% were Hispanic, and 13.6% were of other race/ethnicity. Almost two thirds (61.8%) of respondents were pediatricians, 22.3% were nurse practitioners and physician assistants, and 15.8% were family medicine physicians. Two thirds (65%) were outpatient-only providers, and 35% provided care in both inpatient and outpatient settings. Most were practicing in the Albuquerque area (80%). Reported counseling about breastfeeding We examined the percentage of providers reporting that they always provided breastfeeding counseling at specific well-baby visits and which topics were addressed (Table 1). Almost all providers reported routinely asking parents about feeding methods (i.e., if they were breastfeeding, formula feeding, or both) at the first newborn visit, 10- to 14-day visit, 2-month visit, and 4-month visit. However, fewer than half of providers
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reported that they asked parents how long they planned to exclusively breastfeed and how long they planned to continue breastfeeding after the introduction of complementary foods at the first or second visit. Just over half reported asking about parents’ plans for breastfeeding after they returned to work or school. Furthermore, although nearly all providers reported asking parents about breastfeeding problems or concerns at the first or second visit, only half (53.6%) reported that they continued asking about problems or concerns at the 2-month visit, and a third (34.3%) reported that they continued asking about problems or concerns at the 4-month visit. Knowledge and confidence Three quarters (77.0%) of participants correctly responded that babies should breastfeed exclusively for the first 6 months of life, and 86.5% correctly responded that babies should continue to breastfeed after the introduction of complementary foods until at least 12 months of age (data not shown in tables). Table 2 shows how providers responded to statements assessing their knowledge and confidence regarding breastfeeding counseling. More than a quarter of participants incorrectly responded that hepatitis C virus (HCV) was an absolute contraindication to breastfeeding (Table 2). Participants reported a lack of confidence in their ability to provide counseling to families about a range of breastfeeding topics including home visitation programs and feeding options when mothers have serious medical conditions (such as HIV or HCV), have substance use concerns, or have common concerns such as mastitis (Table 2). Reported discussions about resources Almost all participants (97.3%) had discussed or recommended a lactation consult, and most had discussed or recommended obtaining an electric breast pump through the Special Supplemental Nutrition Program for Women, Infants and Children (WIC) program (80.8%) or the mother’s insurance provider (79.7%). Other resources were less used, however. Fewer than half of providers reported discussing or recommending the WIC peer counseling program, and 44.4% reported that they were unaware of the WIC peer
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TABLE 2. Provider knowledge and confidence in discussing breastfeeding topics—New Mexico Pediatric Provider Survey, 2016 Item
Confidence discussing . . . Home visitation programs Feeding options for babies whose mothers are HIV+, hepatitis C+, or have other serious medical conditions Breastfeeding and substance use Management of mastitis Management of breast engorgement Breastfeeding and maternal medications Management of painful nipples A good latch Breastfeeding support resources Positioning of baby for breastfeeding
Disagree, %b
97.4
2.6
97.4 92.2 81.6 29.4 28.2 13.5
2.6 7.8 18.4 70.6 71.2 86.5
Not at All Confident, %
Somewhat Confident, %
Very Confident, %
44.7 29.3
31.6 49.3
23.7 21.3%
27.6 17.1 12.2 10.5 10.5 8.0 5.3 5.3
48.7 51.3 43.2 57.9 48.7 37.3 58.7 38.2
23.7 31.6 44.6 31.6 40.8 54.7 36.0 56.6
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Note. N = 77 family and pediatric nurse practitioners, family medicine and pediatric physicians, and physician assistants Agree = Somewhat agree or Strongly agree b Disagree = Somewhat disagree or Strongly disagree a
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Knowledge Medically stable newborns should remain skin-to-skin with their mothers (or other family member if mother unable) for at least the first hour of life Newborns should breastfeed on demand, with a goal of 8 12 times in a 24-hour period A mother should continue breastfeeding if she develops a breast infection (mastitis) Early supplementation with formula can result in insufficient breast milk supply Babies should be able to sleep through the night by 2 months of age A mother who is hepatitis C positive should never breastfeed Babies should stop breastfeeding when they are 12 months old
Agree, %a
ARTICLE IN PRESS TABLE 3. Continuing education on breastfeeding topics that outpatient providers consider very important to their practice and have received—New Mexico Provider Survey, 2016 Management of common breastfeeding problems Breastfeeding and maternal medications Contraindications to breastfeeding Breastfeeding promotion and support The Ten Steps to Successful Breastfeedinga Home visitation programs
Very important to practice, %
Have received in the past 3 years, %
75.0 72.2 71.1 64.0 60.0 53.3
52.7 30.7 44.0 70.1 55.3 31.2
Note. N = 77 family and pediatric nurse practitioners, pediatricians, and physician assistants. a The Ten Steps to Successful Breastfeeding is evidence-based guidance from Baby-Friendly USA, available at https://www.babyfriendlyusa. org/about-us/10-steps-and-international-code.
counseling program. Only a third (39.4%) had discussed or recommended a home visitation program, and a third (29.6%) were not aware of this resource. Continuing education Most providers reported that receiving continuing education on a variety of breastfeeding topics was “very important” to their practice (Table 3). However, reported receipt of continuing education on these topics was variably low. For instance, although 72.2% of participants reported that continuing education on breastfeeding and maternal medications was very important to their practice, only 30.7% reported receiving education on this topic in the past 3 years. Focus Group Findings A total of 17 pediatric providers participated in three focus groups: 13 pediatricians, three nurse practitioners, and one physician assistant. Common themes that emerged were that providers endorsed a sense of role responsibility regarding supporting breastfeeding and acknowledged gaps in knowledge and a lack of confidence in their counseling. Providers endorsed a high level of role responsibility for supporting mothers in breastfeeding. As one provider stated, “We are very important to the success of a mom breastfeeding.” Another noted, “We need to take on more responsibility.” Another commented, “Most of the time nurses or lactation consultants have these talks, but we feel we need to better support mothers, especially when they go back to work.” Both provider time Both provider time and lack of provider education were recognized and lack of provider as major obstacles to education were improving supports for recognized as major breastfeeding women in the outpatient pediatric obstacles to setting. “We need someimproving supports one to streamline our for breastfeeding processes in clinic so that we have more time to women in the talk to moms.” Providers outpatient pediatric were forthcoming about setting. gaps in knowledge. “We www.jpedhc.org
need more structure and education to improve adherence to best practice guidelines.” Providers acknowledged that knowledge gaps affected their confidence in their guidance. “We need more knowledge, handouts, and support to be more comfortable.” When providers were asked if they felt confident in their ability to address things like maternal medications while breastfeeding, a majority said no.
DISCUSSION In anticipation of a planned public health intervention in our state, we conducted a mixed-methods (quantitative and qualitative) study of outpatient pediatric providers to investigate provider knowledge and practices regarding supports for breastfeeding mothers. We identified multiple missed opportunities for outpatient providers to provide evidencebased guidance to support breastfeeding. We also identified specific topic areas of continuing education that providers considered important for their practices but had not recently (i.e., in the past 3 years) received. Reported Counseling About Breastfeeding Plans Our findings indicate that providers are missing opportunities to support breastfeeding during routine well-baby outpatient visits. Although most providers in our sample asked parents if they were breastfeeding or formula-feeding at the first or second well-baby visit, fewer than half of providers reported using those visits to ask about their plans to exclusively breastfeed and how long they planned to continue breastfeeding after the introduction of complementary foods. Just over half reported asking parents about their plans for breastfeeding after mothers returned to work or school. Furthermore, although most providers reported asking parents about problems or concerns with breastfeeding at early well-baby visits, relatively few reported asking about problems or concerns after the second newborn visit. These represent missed opportunities to discuss plans for breastfeeding and to troubleshoot potential barriers to continued breastfeeding. Mothers may not plan to continue breastfeeding after returning to work or school because they do not believe it will be feasible. These are opportunities for providers to explore community resources (e.g., breast
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ARTICLE IN PRESS pumps and WIC peer support counselors), help mothers develop a plan to discuss pumping with their employers or schools, and, at the very least, encourage continued breastfeeding when the mother is home with her baby. Furthermore, mothers may discontinue breastfeeding earlier than they originally planned if issues that they do not know how to deal with arise, such as the need to take a new medication. Providers can help prepare breastfeeding mothers in advance to deal with such unforeseen issues and to navigate the available resources that can help them to breastfeed longer and without formula supplementation. However, this requires that providers be better informed. Knowledge and Confidence Our findings regarding provider knowledge deficits are consistent with previous research reporting generally low levels of knowledge and confidence related to breastfeeding support among providers (AACOG Committee on Obstetric Practice Breastfeeding Expert Work Group, 2016; Cleminson, Oddie, Renfrew, & McGuire, 2015; Demirci et al., 2013; Pound, Moreau, Hart, Ward, & Plint, 2015; Pound, Williams, Grenon, Aglipay, & Plint, 2014; Sloand, Lowe, Pennington, & Rose, 2018). We identified specific knowledge gaps that could impede support for breastfeeding mothers dealing with both common and complex breastfeeding issues. Our finding that almost 20% of providers surveyed did not believe that formula supplementation could contribute to a diminished milk supply was consistent with a survey report from Canada (Pound et al., 2014). More than a quarter of providers in our study reported erroneously that babies should be able to sleep through the night by 2 months of age. This expectation is not developmentally appropriate and is among the oftencited reasons for early supplementation with formula (Ridgway et al., 2016; Spencer, Greatrex-White, & Fraser, 2014). Provider lack of knowledge is further reflected in the low levels of confidence providers reported in dealing with common breastfeeding issues such as breast engorgement, painful nipples, and mastitis. Fewer than half of providers surveyed said they felt very confident discussing these topics. Even fewer expressed confidence dealing with more complex issues, like maternal medications. Davanzo et al. (2016) found that although two thirds of breastfeeding women use medications, there is a lack of professional guidance and knowledge among providers regarding the use of medications while breastfeeding. This lack of knowledge may result in providers taking an overly cautious approach to the use of medications by breastfeeding women, including recommending breaks in breastfeeding that can put babies at risk for early discontinuation of breastfeeding (Davanzo et al., 2016). Cases of HCV are increasing in the United States, where approximately 40,000 children are born to HCV-positive women each year, and an estimated 1% to 2.5% of pregnant women in the United States have HCV (Cottrell, Chou, Wasson, Rahman, & Guise, 2013; Page et al., 2017). HCV infection is not a contraindication to breastfeeding in most cases (AAP, 2018; Centers for Disease Control and Prevention, 6
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2018; Page et al., 2017), yet more than a quarter of the providers we surveyed were unaware of this. Underuse of Resources Providers appear to be underusing available resources that could benefit their patients. Although most had discussed or recommended a lactation consult and ways to obtain an electric pump, few had discussed or referred women to home visitation programs or WIC peer counselors. Peer counseling has been shown to be an effective breastfeeding support intervention (Bibbins-Domingo et al., 2016). However, almost half of the providers we surveyed were unaware of the WIC breastfeeding peer counseling program. Similarly, fewer than half of providers had referred women to a home visitation program, and almost a third were unaware of this resource. Continuing Education We identified continuing education topics that most pediatric providers considered very important to their practices but only a minority had recently received. For instance, fewer than a third of the providers in our survey sample had received continuing education on breastfeeding and maternal medications, yet almost three quarters rated this as very important to their practice. Similarly, only 44% of providers had received continuing education on contraindications to breastfeeding, despite almost three quarters having rated this as very important to their practice. Also, just half of respondents reported receiving continuing education within the past 3 years Just half of about the management respondents of common breastfeedreported receiving ing problems, although three quarters rated this continuing as very important to education within the their practice. Lack of past 3 years about provider education may have been reflected in the management of the lack of certainty we common found among providers breastfeeding about whether early supplementation with problems, although formula can negatively three quarters rated affect milk supply or this as very whether mothers with serious medical condiimportant to their tions (such as HCV practice. infection) should breastfeed.
Role Responsibility Our focus group findings suggest that outpatient pediatric providers endorse a high sense of role responsibility for supporting breastfeeding among patients in their practices but need more clinic support and provider education to do so.
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ARTICLE IN PRESS Specifically, lack of sufficient time during appointments and the need for more education about breastfeeding counseling and support were common themes. Educational approaches that build confidence in provider counseling skills may be especially important.
Limitations and Strengths This study has several limitations. The survey instrument, although created with subject matter expertise and cognitively tested before administration, was not otherwise previously validated. It was administered to a convenience sample of outpatient providers; as such, this was not a population-based sampling, and the results may not be representative of all outpatient providers in the state. Our findings may not be generalizable to providers in other regions of the United States. Our sample size, fewer than 100 providers, precluded more than descriptive analyses. The focus groups were similarly conducted with a purposive sampling, and results may not be generalizable. Despite these limitations, our findings make a timely and important contribution toward advancing breastfeeding supports in the outpatient pediatric setting. Strengths include our use of quantitative and qualitative methods and our identification of providers’ specific knowledge deficits, in particular regarding appropriate counseling for breastfeeding mothers who have HCV infections. Finally, we identified gaps between the continuing education received in the past 3 years and continuing education topics that outpatient pediatric providers reported would be very important for their practice.
CONCLUSIONS This study identified multiple missed opportunities for outpatient providers to support breastfeeding families in both identifying and then realizing their breastfeeding goals. We identified areas of gaps between published evidence-based practice and outpatient pediatric providers’ knowledge and clinical practices. Our results highlight a need for targeted outpatient pediatric provider education around optimal support of breastfeeding, especially when mothers are taking medications, have an infectious disease or concern about substance use, or will return to work or school in their child’s first year of life. Many providers lack confidence in their ability to provide support to breastfeeding families and could benefit not only from increased education but also increased awareness of and access to resources in the community such as home visitation programs and peer support counselors. We plan to use these findings to inform the development of a public health initiative that aims to increase the provision of evidence-based breastfeeding care in the outpatient setting. The authors gratefully thank the providers for their participation in this study. We would like to thank the New Mexico Pediatric Society and our Community Advisory Board for their ongoing support.
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REFERENCES American Academy of Family Physicians. (n.d.) Family physicians supporting breastfeeding [position paper]. Leawood, KS: Author. Retrieved from www.aafp.org/about/policies/all/breast feeding-support.html American Academy of Pediatrics. (2018). Benefits of breastfeeding. Retrieved from Itasca, IL: Author. Retrieved from https://www. aap.org/en-us/advocacy-and-policy/aap-health-initiatives/ Breastfeeding/Pages/Benefits-of-Breastfeeding.aspx American Academy of Pediatrics. (2012). Breastfeeding and the use of human milk. Pediatrics, 129(3), e827–e841. American College of Obstetricians and Gynecologists Committee on Health Care for Underserved Women. (2007). ACOG committee opinion no. 361: Breastfeeding: maternal and infant aspects. Obstetrics and Gynecology, 109(2 Pt. 1), 479–480. American College of Obstetricians and Gynecologists Committee on Obstetric Practice Breastfeeding Expert Work Group. (2016). ACOG committee opinion no. 658: Optimizing support for breastfeeding as part of obstetric practice. Obstetrics and Gynecology, 127(2), e86–e92. Bartick, M. C., Schwarz, E. B., Green, B. D., Jegier, B. J., Reinhold, A. G., Colaizy, T. T., ... Stuebe, A. M. (2017). Suboptimal breastfeeding in the United States: Maternal and pediatric health outcomes and costs. Maternal and Child Nutrition,[Article in Press] doi:10.1111/mcn.12366 Bibbins-Domingo, K., Grossman, D. C., Curry, S. J., Davidson, K. W., Epling, J. W. Jr., Garcia, F. A., & Pignone, M. P. (2016). Primary care interventions to support breastfeeding: US Preventive Services Task Force recommendation statement. JAMA, 316, 1688–1693. Bonuck, K., Stuebe, A., Barnett, J., Labbok, M. H., Fletcher, J., & Bernstein, P. S. (2014). Effect of primary care intervention on breastfeeding duration and intensity. American Journal of Publich Health, 104(Suppl. 1), S119–S127. Busch, D. W., Logan, K., & Wilkinson, A. (2014). Clinical practice breastfeeding recommendations for primary care: Applying a tri-core breastfeeding conceptual model. Journal of Pediatric Health Care, 28, 486–496. Centers for Disease Control and Prevention. (2017). CDC national immunization survey: Breastfeeding among US children born 2001-2013. Retrieved from Atlanta, GA: Author. Retrieved from www.cdc.gov/breastfeeding/data/nis_data/index.htm Centers for Disease Control and Prevention. (2018). Breastfeeding: Hepatitis B or C infections. Retreived from Atlanta, GA: Author. Retreived from https://www.cdc.gov/breastfeeding/breastfeed ing-special-circumstances/maternal-or-infant-illnesses/hepati tis.html Cleminson, J., Oddie, S., Renfrew, M. J., & McGuire, W. (2015). Being baby friendly: eEvidence-based breastfeeding support. Archives of Disease in Childhood. Fetal and Neonatal Edition, 100, F173–F178. Cottrell, E. B., Chou, R., Wasson, N., Rahman, B., & Guise, J. M. (2013). Reducing risk for mother-to-infant transmission of hepatitis C virus: A systematic review for the U.S. Preventive Services Task Force. Annals of Internal Medicine, 158, 109–113. Davanzo, R., Bua, J., De Cunto, A., Farina, M. L., De Ponti, F., Clavenna, A., ... Clementi, M. (2016). Advising mothers on the use of medications during breastfeeding: A need for a positive attitude. Journal of Human Lactation, 32, 15–19. Demirci, J. R., Bogen, D. L., Holland, C., Tarr, J. A., Rubio, D., Li, J., & Chang, J. C. (2013). Characteristics of breastfeeding discussions at the initial prenatal visit. Obstetrics and Gynecology, 122, 1263–1270. Harris, P. A., Taylor, R., Thielke, R., Payne, J., Gonzalez, N., & Conde, J. G. (2009). Research electronic data capture (REDCap)—A metadata-driven methodology and workflow process for providing translational research informatics support. Journal of Biomedical Informatics, 42, 377–381.
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ARTICLE IN PRESS Kornides, M., & Kitsantas, P. (2013). Evaluation of breastfeeding promotion, support, and knowledge of benefits on breastfeeding outcomes. Jouranl of Child Health Care, 17, 264–273. Meek, J. Y., & Hatcher, A. J. (2017). AAP Section on Breastfeeding. (2017). The breastfeeding-friendly pediatric office practice. Pediatrics, 139,(5) e20170647. National Association of Pediatric Nurse Practitioners. (2013). NAPNAP position statement on breastfeeding. Journal of Pediatric Health Care, 27(1), e13–e15. Odom, E. C., Li, R., Scanlon, K. S., Perrine, C. G., & Grummer-Strawn, L. (2014). Association of family and health care provider opinion on infant feeding with mother’s breastfeeding decision. Journal of the Academy of Nutrition and Dietetics, 114, 1203–1207. Page, C. M., Hughes, B. L., Rhee, E. H. J., & Kuller, J. A. (2017). Hepatitis C in pregnancy: Review of current knowledge and updated recommendations for management. Obstetrical and Gynecological Survey, 72(6), 347–355. Patnode, C. D., Henninger, M. L., Senger, C. A., Perdue, L. A., & Whitlock, E. P. (2016). Primary care interventions to support breastfeeding updated evidence report and systematic review for the US Preventive Services Task Force. JAMA, 316, 1694–1705. Pound, C. M., Moreau, K. A., Hart, F., Ward, N., & Plint, A. C. (2015). The planning of a national breastfeeding educational intervention for medical residents. Medical Education Online, 20, 26380.
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Pound, C. M., Williams, K., Grenon, R., Aglipay, M., & Plint, A. C. (2014). Breastfeeding knowledge, confidence, beliefs, and attitudes of Canadian physicians. Journal of Human Lactation, 30, 298–309. Ridgway, L., Cramer, R., McLachlan, H. L., Forster, D. A., Cullinane, M., Shafiei, T., & Amir, L. H. (2016). Breastfeeding support in the early postpartum: Content of home visits in the SILC trial. Birth, 43, 303–312. Skouteris, H., Nagle, C., Fowler, M., Kent, B., Sahota, P., & Morris, H. (2014). Interventions designed to promote exclusive breastfeeding in high-income countries: A systematic review. Breastfeeding Medicing, 9, 113–127. Sloand, E., Lowe, V., Pennington, A., & Rose, L. (2018). Breastfeeding practices and opinions of Latina mothers in an urban pediatric office: A focus group study. Journal of Pediatric Health Care. Spencer, R., Greatrex-White, S., & Fraser, D. (2014). ‘I was meant to be able to do this’: A phenomenological study of women’s experiences of breastfeeding. Evidence Based Midwifery, 12, 83–88. Wallenborn, J. T., Ihongbe, T., Rozario, S., & Masho, S. W. (2017). Knowledge of breastfeeding recommendations and breastfeeding duration: A survival analysis on infant feeding practices II. Breastfeeding Medicing, 12, 156–162. World Health Organization. (n.d.). Breastfeeding. Geneva, Switzerland: Author. Retrieved from http://www.who.int/nutrition/ topics/exclusive_breastfeeding/en/
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Missed Opportunities in the Outpatient Pediatric Setting to Support Breastfeeding: Results From a MixedMethods Study D1X XMary M. Ramos, D2X XMD, MPH, D3X XRachel A. Sebastian, D4X XMA, D5X XEmilie Sebesta, D6X XJD, MD, D7X XAdrienne E. McConnell, D8X XMS, & D9X XCourtney R. McKinney, D10X XBA ABSTRACT Introduction: Outpatient pediatric providers play a crucial role in the promotion of breastfeeding. We conducted a mixed methods Mary M. Ramos, Assistant Professor, Department of Pediatrics, University of New Mexico School of Medicine, Albuquerque, NM. Rachel A. Sebastian, Medical Sociologist, Child Policy Research Consulting, LLC, Fort Wright, KY. Emilie Sebesta, Professor, Department of Pediatrics, University of New Mexico School of Medicine, Albuquerque, NM. Adrienne E. McConnell, Health Education Consultant, Department of Pediatrics, University of New Mexico School of Medicine, Albuquerque, NM. Courtney R. McKinney, Program Manager, Department of Pediatrics, University of New Mexico School of Medicine, Albuquerque, NM.
study to measure provider knowledge, attitudes, and current practices around breastfeeding counseling. Method: In New Mexico in 2016 and 2017, we conducted a knowledge, attitudes, and practice survey of outpatient pediatric providers (i.e., nurse practitioners, physicians, and physician assistants) and conducted focus groups with outpatient pediatric providers. Results: Seventy-seven providers responded to the survey, and 17 participated in three focus groups. Fewer than half of providers surveyed reported asking how long mothers plan to breastfeed at initial well-baby examinations. One quarter of participants (28.2%) erroneously reported that hepatitis C was an absolute contraindication to breastfeeding. Just half of respondents had received continuing education within the past 3 years about managing common breastfeeding problems. Discussion: We identified missed opportunities for outpatient pediatric providers to support breastfeeding and a need for continuing provider education. J Pediatr Health Care. (2018) XX, 1 8
Conflicts of interest: None to report. This work was supported by the W.K. Kellogg Foundation (grant number P3034276) and the New Mexico Human Services Department (grant number 14-630-8000-0008 A2). The funding agencies played no role in the study design; collection, analysis and interpretation of data; in the writing of this article; or in the decision to submit this article for publication.
KEY WORDS
Correspondence: Mary M. Ramos, MD, MPH, MSC 10 5590, 1 University of New Mexico, Albuquerque, NM 87131-0001; e-mail: [email protected]. J Pediatr Health Care. (2018) &&, && &&
INTRODUCTION There is overwhelming evidence of the benefits of breastfeeding for both infants and women. Because of this evidence, the American Academy of Pediatrics (AAP), American Academy of Family Physicians (AAFP), American College of Obstetricians and Gynecologists (ACOG), National Association of Pediatric Nurse Practitioners, and the World Health Organization recommend exclusive breastfeeding for the first 6
0891-5245/$36.00 Copyright © 2018 by the National Association of Pediatric Nurse Practitioners. Published by Elsevier Inc. All rights reserved. https://doi.org/10.1016/j.pedhc.2018.06.004
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Breastfeeding, breastfeeding support, outpatient, provider confidence, provider knowledge
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ARTICLE IN PRESS months of a child’s life and continued breastfeeding after the introduction of complementary foods for at least 1 to 2 years (AAFP, n.d.; AAP, 2012; ACOG Committee on Health Care for Underserved Women, 2007; ACOG Committee on Obstetric Practice Breastfeeding Expert Work Group, 2016; National Association of Pediatric Nurse Practitioners, 2013; World Health Organization, n.d.). However, approximately half of the women in the United States who initiate breastfeeding will discontinue breastfeeding by 6 months (Centers for Disease Control and Prevention, 2017). In the United States alone, an estimated 2,619 annual maternal deaths (mostly due to myocardial infarction, breast cancer, and diabetes) and 721 annual pediatric deaths (mostly due to sudden infant death syndrome and necrotizing enterocolitis) are attributed to this suboptimal breastfeeding (Bartick et al., 2017). The estimated annual medical costs of suboptimal breastfeeding in the United States total $3.0 billion (Bartick et al., 2017). Outpatient pediatric practices play a crucial role in the promotion and support of breastfeeding (Kornides & Kitsantas, 2013; Meek et al., 2017). Provider interventions, for example, counseling and information, have a significant effect on the initiation and duration of exclusive breastfeeding in the first 6 months of life and overall duration (Kornides & Kitsantas, 2013; Odom, Li, Scanlon, Perrine, & Grummer-Strawn, 2014; Patnode, Henninger, Senger, Perdue, & Whitlock, 2016). Women are more likely to initiate breastfeeding when their providers are supportive of exclusive breastfeeding (Kornides & Kitsantas, 2013; Odom et al., 2014). Furthermore, women who have knowledge of breastfeeding recommendations are less likely to discontinue breastfeeding than women who do not have knowledge of breastfeeding recommendations (Wallenborn, Ihongbe, Rozario, & Masho, 2017). Breastfeeding support interventions, including educational counseling and referrals, are associated with increased rates of any and exclusive breastfeeding (Patnode et al., 2016; Skouteris et al., 2014). Previous findings also support the use of lactation consultants and peer counselors (Bibbins-Domingo et al., 2016; Bonuck et al., 2014). Because of the direct link between breastfeeding and maternal and infant health outcomes, the AAP recommends that all pediatric care providers work to improve breastfeeding rates in their practices and has published guidance on establishing breastfeeding-friendly pediatric office practices (Meek et al., 2017). The Tri-core Breastfeeding Model (Busch et al., 2014) provides a framework for pediatric nurse practitioners to integrate evidencebased knowledge, skills, and attitudes supportive of breastfeeding into their clinical practices. The model emphasizes sustainability for the mother baby dyad through maternal self-efficacy, lactation support, and lactation education for mothers and health care professionals (Busch, Logan, & Wilkinson, 2014). As a foundational step of a planned public health intervention aimed at increasing breastfeeding exclusivity and duration, we surveyed outpatient pediatric providers (i.e., nurse practitioners, physicians, and physician assistants) to measure their 2
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knowledge, attitudes, and current practices around breastfeeding counseling and support. We also conducted focus groups with outpatient pediatric providers to confirm We sought to and triangulate survey identify gaps findings. We sought to identify gaps between between best best practices and actual practices and actual provider knowledge and provider knowledge counseling.
and counseling. METHODS Survey Instrument Subject matter experts in pediatrics, nursing, public health, and quality improvement created the 51-item survey instrument to measure the breastfeeding knowledge, confidence, and counseling practices of outpatient pediatric providers (i.e., nurse practitioners, physicians, and physician assistants). The survey was then cognitively tested by four pediatric providers to ensure content validity before administration. Specific survey domains included demographics, professional characteristics, knowledge of current professional guidance around breastfeeding, breastfeeding counseling practice, confidence in their counseling, and continuing education. Administration The survey was conducted anonymously. The survey instrument was administered in paper copy to providers who attended the New Mexico Pediatrics Society annual meeting in Albuquerque, New Mexico in August 2016, and then the identical survey was administered electronically using Research Electronic Data Capture (i.e., REDCap; Harris et al., 2009). Members of the New Mexico Pediatric Society, the University of New Mexico General Pediatrics and Family Medicine faculty, and outpatient provider groups across the state, including eight federally qualified health centers, were contacted through e-mail and asked to complete the survey. The e-mail notice included an anonymous Web link to the REDCap survey. Two weeks after the initial e-mail notice, a reminder notice with the Web link to the survey was e-mailed. Completed surveys were received from August 2016 through December 2016. Data analysis We included all respondents to the survey who self-identified as being an outpatient pediatric provider (i.e., nurse practitioners, physicians, and physician assistants). The study design was cross-sectional. We calculated proportions and frequencies. Focus Groups We conducted focus groups with pediatric providers in the two largest metropolitan areas of the state. The first two were held in central New Mexico on April 21, 2017, and the
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ARTICLE IN PRESS TABLE 1. Percentage of providers who always ask about breastfeeding at well-baby visits— New Mexico Pediatric Provider Survey, 2016 Providers who always ask at first or second visit, % How long mothers plan to exclusively breastfeed How long mothers plan to breastfeed in total
40.8 31.0 Providers who always ask at specific well-baby visits, %
If baby is breastfeeding, formula-feeding, or both If breastfeeding, any problems or concerns If breastfeeding, plans to continue after returning to work or school
1st Newborn Visit
10- to 14-Day Visit
2-Month Visit
4-Month Visit
98.6 94.4 56.9
97.2 95.7 59.2
94.4 53.6 65.7
94.4 34.3 Not asked
Note. N = 77 family and pediatric nurse practitioners, family medicine and pediatric physicians, and physician assistants.
third was held in southern New Mexico on June 16, 2017. Providers in the focus groups were asked semistructured questions about their attitudes toward breastfeeding, knowledge and agreement with breastfeeding recommendations, sense of role responsibility related to breastfeeding counseling and support, current practices, and readiness to improve breastfeeding supports in their practices. Focus groups were conducted by four study members: two pediatricians and two quality improvement experts. Each focus group included at least one interviewer and one note taker. Notes were taken by hand, transcribed, and first reviewed by one study team member with expertise in qualitative data to examine common themes versus concerns of individual participants. The final themes that emerged were constructed through a consensus of study team members. Ethical Review The study protocol was approved by the authors’ Human Research Protections Office (HRC HRPO # 6-200). RESULTS Survey Findings Participants A total of 77 outpatient pediatric providers participated in the survey. Most (75%) were 40 years old or older. Most participants (59.5%) were non-Hispanic White; 27.0% were Hispanic, and 13.6% were of other race/ethnicity. Almost two thirds (61.8%) of respondents were pediatricians, 22.3% were nurse practitioners and physician assistants, and 15.8% were family medicine physicians. Two thirds (65%) were outpatient-only providers, and 35% provided care in both inpatient and outpatient settings. Most were practicing in the Albuquerque area (80%). Reported counseling about breastfeeding We examined the percentage of providers reporting that they always provided breastfeeding counseling at specific well-baby visits and which topics were addressed (Table 1). Almost all providers reported routinely asking parents about feeding methods (i.e., if they were breastfeeding, formula feeding, or both) at the first newborn visit, 10- to 14-day visit, 2-month visit, and 4-month visit. However, fewer than half of providers
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reported that they asked parents how long they planned to exclusively breastfeed and how long they planned to continue breastfeeding after the introduction of complementary foods at the first or second visit. Just over half reported asking about parents’ plans for breastfeeding after they returned to work or school. Furthermore, although nearly all providers reported asking parents about breastfeeding problems or concerns at the first or second visit, only half (53.6%) reported that they continued asking about problems or concerns at the 2-month visit, and a third (34.3%) reported that they continued asking about problems or concerns at the 4-month visit. Knowledge and confidence Three quarters (77.0%) of participants correctly responded that babies should breastfeed exclusively for the first 6 months of life, and 86.5% correctly responded that babies should continue to breastfeed after the introduction of complementary foods until at least 12 months of age (data not shown in tables). Table 2 shows how providers responded to statements assessing their knowledge and confidence regarding breastfeeding counseling. More than a quarter of participants incorrectly responded that hepatitis C virus (HCV) was an absolute contraindication to breastfeeding (Table 2). Participants reported a lack of confidence in their ability to provide counseling to families about a range of breastfeeding topics including home visitation programs and feeding options when mothers have serious medical conditions (such as HIV or HCV), have substance use concerns, or have common concerns such as mastitis (Table 2). Reported discussions about resources Almost all participants (97.3%) had discussed or recommended a lactation consult, and most had discussed or recommended obtaining an electric breast pump through the Special Supplemental Nutrition Program for Women, Infants and Children (WIC) program (80.8%) or the mother’s insurance provider (79.7%). Other resources were less used, however. Fewer than half of providers reported discussing or recommending the WIC peer counseling program, and 44.4% reported that they were unaware of the WIC peer
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TABLE 2. Provider knowledge and confidence in discussing breastfeeding topics—New Mexico Pediatric Provider Survey, 2016 Item
Confidence discussing . . . Home visitation programs Feeding options for babies whose mothers are HIV+, hepatitis C+, or have other serious medical conditions Breastfeeding and substance use Management of mastitis Management of breast engorgement Breastfeeding and maternal medications Management of painful nipples A good latch Breastfeeding support resources Positioning of baby for breastfeeding
Disagree, %b
97.4
2.6
97.4 92.2 81.6 29.4 28.2 13.5
2.6 7.8 18.4 70.6 71.2 86.5
Not at All Confident, %
Somewhat Confident, %
Very Confident, %
44.7 29.3
31.6 49.3
23.7 21.3%
27.6 17.1 12.2 10.5 10.5 8.0 5.3 5.3
48.7 51.3 43.2 57.9 48.7 37.3 58.7 38.2
23.7 31.6 44.6 31.6 40.8 54.7 36.0 56.6
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Note. N = 77 family and pediatric nurse practitioners, family medicine and pediatric physicians, and physician assistants Agree = Somewhat agree or Strongly agree b Disagree = Somewhat disagree or Strongly disagree a
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Knowledge Medically stable newborns should remain skin-to-skin with their mothers (or other family member if mother unable) for at least the first hour of life Newborns should breastfeed on demand, with a goal of 8 12 times in a 24-hour period A mother should continue breastfeeding if she develops a breast infection (mastitis) Early supplementation with formula can result in insufficient breast milk supply Babies should be able to sleep through the night by 2 months of age A mother who is hepatitis C positive should never breastfeed Babies should stop breastfeeding when they are 12 months old
Agree, %a
ARTICLE IN PRESS TABLE 3. Continuing education on breastfeeding topics that outpatient providers consider very important to their practice and have received—New Mexico Provider Survey, 2016 Management of common breastfeeding problems Breastfeeding and maternal medications Contraindications to breastfeeding Breastfeeding promotion and support The Ten Steps to Successful Breastfeedinga Home visitation programs
Very important to practice, %
Have received in the past 3 years, %
75.0 72.2 71.1 64.0 60.0 53.3
52.7 30.7 44.0 70.1 55.3 31.2
Note. N = 77 family and pediatric nurse practitioners, pediatricians, and physician assistants. a The Ten Steps to Successful Breastfeeding is evidence-based guidance from Baby-Friendly USA, available at https://www.babyfriendlyusa. org/about-us/10-steps-and-international-code.
counseling program. Only a third (39.4%) had discussed or recommended a home visitation program, and a third (29.6%) were not aware of this resource. Continuing education Most providers reported that receiving continuing education on a variety of breastfeeding topics was “very important” to their practice (Table 3). However, reported receipt of continuing education on these topics was variably low. For instance, although 72.2% of participants reported that continuing education on breastfeeding and maternal medications was very important to their practice, only 30.7% reported receiving education on this topic in the past 3 years. Focus Group Findings A total of 17 pediatric providers participated in three focus groups: 13 pediatricians, three nurse practitioners, and one physician assistant. Common themes that emerged were that providers endorsed a sense of role responsibility regarding supporting breastfeeding and acknowledged gaps in knowledge and a lack of confidence in their counseling. Providers endorsed a high level of role responsibility for supporting mothers in breastfeeding. As one provider stated, “We are very important to the success of a mom breastfeeding.” Another noted, “We need to take on more responsibility.” Another commented, “Most of the time nurses or lactation consultants have these talks, but we feel we need to better support mothers, especially when they go back to work.” Both provider time Both provider time and lack of provider education were recognized and lack of provider as major obstacles to education were improving supports for recognized as major breastfeeding women in the outpatient pediatric obstacles to setting. “We need someimproving supports one to streamline our for breastfeeding processes in clinic so that we have more time to women in the talk to moms.” Providers outpatient pediatric were forthcoming about setting. gaps in knowledge. “We www.jpedhc.org
need more structure and education to improve adherence to best practice guidelines.” Providers acknowledged that knowledge gaps affected their confidence in their guidance. “We need more knowledge, handouts, and support to be more comfortable.” When providers were asked if they felt confident in their ability to address things like maternal medications while breastfeeding, a majority said no.
DISCUSSION In anticipation of a planned public health intervention in our state, we conducted a mixed-methods (quantitative and qualitative) study of outpatient pediatric providers to investigate provider knowledge and practices regarding supports for breastfeeding mothers. We identified multiple missed opportunities for outpatient providers to provide evidencebased guidance to support breastfeeding. We also identified specific topic areas of continuing education that providers considered important for their practices but had not recently (i.e., in the past 3 years) received. Reported Counseling About Breastfeeding Plans Our findings indicate that providers are missing opportunities to support breastfeeding during routine well-baby outpatient visits. Although most providers in our sample asked parents if they were breastfeeding or formula-feeding at the first or second well-baby visit, fewer than half of providers reported using those visits to ask about their plans to exclusively breastfeed and how long they planned to continue breastfeeding after the introduction of complementary foods. Just over half reported asking parents about their plans for breastfeeding after mothers returned to work or school. Furthermore, although most providers reported asking parents about problems or concerns with breastfeeding at early well-baby visits, relatively few reported asking about problems or concerns after the second newborn visit. These represent missed opportunities to discuss plans for breastfeeding and to troubleshoot potential barriers to continued breastfeeding. Mothers may not plan to continue breastfeeding after returning to work or school because they do not believe it will be feasible. These are opportunities for providers to explore community resources (e.g., breast
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ARTICLE IN PRESS pumps and WIC peer support counselors), help mothers develop a plan to discuss pumping with their employers or schools, and, at the very least, encourage continued breastfeeding when the mother is home with her baby. Furthermore, mothers may discontinue breastfeeding earlier than they originally planned if issues that they do not know how to deal with arise, such as the need to take a new medication. Providers can help prepare breastfeeding mothers in advance to deal with such unforeseen issues and to navigate the available resources that can help them to breastfeed longer and without formula supplementation. However, this requires that providers be better informed. Knowledge and Confidence Our findings regarding provider knowledge deficits are consistent with previous research reporting generally low levels of knowledge and confidence related to breastfeeding support among providers (AACOG Committee on Obstetric Practice Breastfeeding Expert Work Group, 2016; Cleminson, Oddie, Renfrew, & McGuire, 2015; Demirci et al., 2013; Pound, Moreau, Hart, Ward, & Plint, 2015; Pound, Williams, Grenon, Aglipay, & Plint, 2014; Sloand, Lowe, Pennington, & Rose, 2018). We identified specific knowledge gaps that could impede support for breastfeeding mothers dealing with both common and complex breastfeeding issues. Our finding that almost 20% of providers surveyed did not believe that formula supplementation could contribute to a diminished milk supply was consistent with a survey report from Canada (Pound et al., 2014). More than a quarter of providers in our study reported erroneously that babies should be able to sleep through the night by 2 months of age. This expectation is not developmentally appropriate and is among the oftencited reasons for early supplementation with formula (Ridgway et al., 2016; Spencer, Greatrex-White, & Fraser, 2014). Provider lack of knowledge is further reflected in the low levels of confidence providers reported in dealing with common breastfeeding issues such as breast engorgement, painful nipples, and mastitis. Fewer than half of providers surveyed said they felt very confident discussing these topics. Even fewer expressed confidence dealing with more complex issues, like maternal medications. Davanzo et al. (2016) found that although two thirds of breastfeeding women use medications, there is a lack of professional guidance and knowledge among providers regarding the use of medications while breastfeeding. This lack of knowledge may result in providers taking an overly cautious approach to the use of medications by breastfeeding women, including recommending breaks in breastfeeding that can put babies at risk for early discontinuation of breastfeeding (Davanzo et al., 2016). Cases of HCV are increasing in the United States, where approximately 40,000 children are born to HCV-positive women each year, and an estimated 1% to 2.5% of pregnant women in the United States have HCV (Cottrell, Chou, Wasson, Rahman, & Guise, 2013; Page et al., 2017). HCV infection is not a contraindication to breastfeeding in most cases (AAP, 2018; Centers for Disease Control and Prevention, 6
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2018; Page et al., 2017), yet more than a quarter of the providers we surveyed were unaware of this. Underuse of Resources Providers appear to be underusing available resources that could benefit their patients. Although most had discussed or recommended a lactation consult and ways to obtain an electric pump, few had discussed or referred women to home visitation programs or WIC peer counselors. Peer counseling has been shown to be an effective breastfeeding support intervention (Bibbins-Domingo et al., 2016). However, almost half of the providers we surveyed were unaware of the WIC breastfeeding peer counseling program. Similarly, fewer than half of providers had referred women to a home visitation program, and almost a third were unaware of this resource. Continuing Education We identified continuing education topics that most pediatric providers considered very important to their practices but only a minority had recently received. For instance, fewer than a third of the providers in our survey sample had received continuing education on breastfeeding and maternal medications, yet almost three quarters rated this as very important to their practice. Similarly, only 44% of providers had received continuing education on contraindications to breastfeeding, despite almost three quarters having rated this as very important to their practice. Also, just half of respondents reported receiving continuing education within the past 3 years Just half of about the management respondents of common breastfeedreported receiving ing problems, although three quarters rated this continuing as very important to education within the their practice. Lack of past 3 years about provider education may have been reflected in the management of the lack of certainty we common found among providers breastfeeding about whether early supplementation with problems, although formula can negatively three quarters rated affect milk supply or this as very whether mothers with serious medical condiimportant to their tions (such as HCV practice. infection) should breastfeed.
Role Responsibility Our focus group findings suggest that outpatient pediatric providers endorse a high sense of role responsibility for supporting breastfeeding among patients in their practices but need more clinic support and provider education to do so.
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ARTICLE IN PRESS Specifically, lack of sufficient time during appointments and the need for more education about breastfeeding counseling and support were common themes. Educational approaches that build confidence in provider counseling skills may be especially important.
Limitations and Strengths This study has several limitations. The survey instrument, although created with subject matter expertise and cognitively tested before administration, was not otherwise previously validated. It was administered to a convenience sample of outpatient providers; as such, this was not a population-based sampling, and the results may not be representative of all outpatient providers in the state. Our findings may not be generalizable to providers in other regions of the United States. Our sample size, fewer than 100 providers, precluded more than descriptive analyses. The focus groups were similarly conducted with a purposive sampling, and results may not be generalizable. Despite these limitations, our findings make a timely and important contribution toward advancing breastfeeding supports in the outpatient pediatric setting. Strengths include our use of quantitative and qualitative methods and our identification of providers’ specific knowledge deficits, in particular regarding appropriate counseling for breastfeeding mothers who have HCV infections. Finally, we identified gaps between the continuing education received in the past 3 years and continuing education topics that outpatient pediatric providers reported would be very important for their practice.
CONCLUSIONS This study identified multiple missed opportunities for outpatient providers to support breastfeeding families in both identifying and then realizing their breastfeeding goals. We identified areas of gaps between published evidence-based practice and outpatient pediatric providers’ knowledge and clinical practices. Our results highlight a need for targeted outpatient pediatric provider education around optimal support of breastfeeding, especially when mothers are taking medications, have an infectious disease or concern about substance use, or will return to work or school in their child’s first year of life. Many providers lack confidence in their ability to provide support to breastfeeding families and could benefit not only from increased education but also increased awareness of and access to resources in the community such as home visitation programs and peer support counselors. We plan to use these findings to inform the development of a public health initiative that aims to increase the provision of evidence-based breastfeeding care in the outpatient setting. The authors gratefully thank the providers for their participation in this study. We would like to thank the New Mexico Pediatric Society and our Community Advisory Board for their ongoing support.
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REFERENCES American Academy of Family Physicians. (n.d.) Family physicians supporting breastfeeding [position paper]. Leawood, KS: Author. Retrieved from www.aafp.org/about/policies/all/breast feeding-support.html American Academy of Pediatrics. (2018). Benefits of breastfeeding. Retrieved from Itasca, IL: Author. Retrieved from https://www. aap.org/en-us/advocacy-and-policy/aap-health-initiatives/ Breastfeeding/Pages/Benefits-of-Breastfeeding.aspx American Academy of Pediatrics. (2012). Breastfeeding and the use of human milk. Pediatrics, 129(3), e827–e841. American College of Obstetricians and Gynecologists Committee on Health Care for Underserved Women. (2007). ACOG committee opinion no. 361: Breastfeeding: maternal and infant aspects. Obstetrics and Gynecology, 109(2 Pt. 1), 479–480. American College of Obstetricians and Gynecologists Committee on Obstetric Practice Breastfeeding Expert Work Group. (2016). ACOG committee opinion no. 658: Optimizing support for breastfeeding as part of obstetric practice. Obstetrics and Gynecology, 127(2), e86–e92. Bartick, M. C., Schwarz, E. B., Green, B. D., Jegier, B. J., Reinhold, A. G., Colaizy, T. T., ... Stuebe, A. M. (2017). Suboptimal breastfeeding in the United States: Maternal and pediatric health outcomes and costs. Maternal and Child Nutrition,[Article in Press] doi:10.1111/mcn.12366 Bibbins-Domingo, K., Grossman, D. C., Curry, S. J., Davidson, K. W., Epling, J. W. Jr., Garcia, F. A., & Pignone, M. P. (2016). Primary care interventions to support breastfeeding: US Preventive Services Task Force recommendation statement. JAMA, 316, 1688–1693. Bonuck, K., Stuebe, A., Barnett, J., Labbok, M. H., Fletcher, J., & Bernstein, P. S. (2014). Effect of primary care intervention on breastfeeding duration and intensity. American Journal of Publich Health, 104(Suppl. 1), S119–S127. Busch, D. W., Logan, K., & Wilkinson, A. (2014). Clinical practice breastfeeding recommendations for primary care: Applying a tri-core breastfeeding conceptual model. Journal of Pediatric Health Care, 28, 486–496. Centers for Disease Control and Prevention. (2017). CDC national immunization survey: Breastfeeding among US children born 2001-2013. Retrieved from Atlanta, GA: Author. Retrieved from www.cdc.gov/breastfeeding/data/nis_data/index.htm Centers for Disease Control and Prevention. (2018). Breastfeeding: Hepatitis B or C infections. Retreived from Atlanta, GA: Author. Retreived from https://www.cdc.gov/breastfeeding/breastfeed ing-special-circumstances/maternal-or-infant-illnesses/hepati tis.html Cleminson, J., Oddie, S., Renfrew, M. J., & McGuire, W. (2015). Being baby friendly: eEvidence-based breastfeeding support. Archives of Disease in Childhood. Fetal and Neonatal Edition, 100, F173–F178. Cottrell, E. B., Chou, R., Wasson, N., Rahman, B., & Guise, J. M. (2013). Reducing risk for mother-to-infant transmission of hepatitis C virus: A systematic review for the U.S. Preventive Services Task Force. Annals of Internal Medicine, 158, 109–113. Davanzo, R., Bua, J., De Cunto, A., Farina, M. L., De Ponti, F., Clavenna, A., ... Clementi, M. (2016). Advising mothers on the use of medications during breastfeeding: A need for a positive attitude. Journal of Human Lactation, 32, 15–19. Demirci, J. R., Bogen, D. L., Holland, C., Tarr, J. A., Rubio, D., Li, J., & Chang, J. C. (2013). Characteristics of breastfeeding discussions at the initial prenatal visit. Obstetrics and Gynecology, 122, 1263–1270. Harris, P. A., Taylor, R., Thielke, R., Payne, J., Gonzalez, N., & Conde, J. G. (2009). Research electronic data capture (REDCap)—A metadata-driven methodology and workflow process for providing translational research informatics support. Journal of Biomedical Informatics, 42, 377–381.
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ARTICLE IN PRESS Kornides, M., & Kitsantas, P. (2013). Evaluation of breastfeeding promotion, support, and knowledge of benefits on breastfeeding outcomes. Jouranl of Child Health Care, 17, 264–273. Meek, J. Y., & Hatcher, A. J. (2017). AAP Section on Breastfeeding. (2017). The breastfeeding-friendly pediatric office practice. Pediatrics, 139,(5) e20170647. National Association of Pediatric Nurse Practitioners. (2013). NAPNAP position statement on breastfeeding. Journal of Pediatric Health Care, 27(1), e13–e15. Odom, E. C., Li, R., Scanlon, K. S., Perrine, C. G., & Grummer-Strawn, L. (2014). Association of family and health care provider opinion on infant feeding with mother’s breastfeeding decision. Journal of the Academy of Nutrition and Dietetics, 114, 1203–1207. Page, C. M., Hughes, B. L., Rhee, E. H. J., & Kuller, J. A. (2017). Hepatitis C in pregnancy: Review of current knowledge and updated recommendations for management. Obstetrical and Gynecological Survey, 72(6), 347–355. Patnode, C. D., Henninger, M. L., Senger, C. A., Perdue, L. A., & Whitlock, E. P. (2016). Primary care interventions to support breastfeeding updated evidence report and systematic review for the US Preventive Services Task Force. JAMA, 316, 1694–1705. Pound, C. M., Moreau, K. A., Hart, F., Ward, N., & Plint, A. C. (2015). The planning of a national breastfeeding educational intervention for medical residents. Medical Education Online, 20, 26380.
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Pound, C. M., Williams, K., Grenon, R., Aglipay, M., & Plint, A. C. (2014). Breastfeeding knowledge, confidence, beliefs, and attitudes of Canadian physicians. Journal of Human Lactation, 30, 298–309. Ridgway, L., Cramer, R., McLachlan, H. L., Forster, D. A., Cullinane, M., Shafiei, T., & Amir, L. H. (2016). Breastfeeding support in the early postpartum: Content of home visits in the SILC trial. Birth, 43, 303–312. Skouteris, H., Nagle, C., Fowler, M., Kent, B., Sahota, P., & Morris, H. (2014). Interventions designed to promote exclusive breastfeeding in high-income countries: A systematic review. Breastfeeding Medicing, 9, 113–127. Sloand, E., Lowe, V., Pennington, A., & Rose, L. (2018). Breastfeeding practices and opinions of Latina mothers in an urban pediatric office: A focus group study. Journal of Pediatric Health Care. Spencer, R., Greatrex-White, S., & Fraser, D. (2014). ‘I was meant to be able to do this’: A phenomenological study of women’s experiences of breastfeeding. Evidence Based Midwifery, 12, 83–88. Wallenborn, J. T., Ihongbe, T., Rozario, S., & Masho, S. W. (2017). Knowledge of breastfeeding recommendations and breastfeeding duration: A survival analysis on infant feeding practices II. Breastfeeding Medicing, 12, 156–162. World Health Organization. (n.d.). Breastfeeding. Geneva, Switzerland: Author. Retrieved from http://www.who.int/nutrition/ topics/exclusive_breastfeeding/en/
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